Retrospective Validation of the Brain Injury Guidelines at a Single Community Institution

Background Traumatic brain injury (TBI) continues to increase in incidence and resource utilization. The Brain Injury Guidelines (BIG) aim to standardize management of isolated blunt TBI and reduce unnecessary interventions; however, adoption in community and regional trauma centers remains limited. We sought to validate BIG criteria at a regional Level I trauma center. Methods We performed a retrospective review of adults with isolated blunt TBI and positive head CT findings from 2018 to 2019. Patients requiring emergent surgery or with polytrauma were excluded. Patients were stratified into BIG 1-3 categories. Outcomes included neurological deterioration (GCS change >2), neurosurgical intervention (Subdural or intraparenchymal Bolt and Craniotomy or craniectomy), mortality, hemorrhage progression, and length of stay. Multivariable logistic regression identified predictors of adverse outcomes. Results Among 557 patients (BIG 1: 30.5%, BIG 2: 19.7%, BIG 3: 49.7%), median age was 77 years, and falls accounted for 86% of injuries. Overall rates of neurological deterioration, neurosurgical intervention, and mortality were 5.4% (n=557), 1.6% (n=557), and 3.6% (n=557), respectively. No BIG 1 patients required neurosurgical intervention, and adverse outcomes were rare. Hemorrhage progression occurred in 12.7% (n=534), most frequently in BIG 3 (17.8%, n=534). Independent predictors of adverse outcomes included BIG 3 classification (OR 6.8), age ≥75 years (OR 2.9), anticoagulation use (OR 2.2), and hemorrhage progression (OR 5.1). Length of stay increased significantly with higher BIG classification (p<0.001). Conclusions The BIG criteria are safe and effective for risk stratification in a regional Level I trauma center. BIG 1 patients demonstrated minimal risk and may not require routine admission, repeat imaging, or neurosurgical consultation. Broader implementation may reduce resource utilization and improve care efficiency without compromising outcomes.